Manage a panel of patients through telephonic outreach, conducting assessments and monitoring remote patient data. Collaborate with the care team to develop individualized care plans and educate patients on chronic disease self-management.
Requirements summary
Requires a valid Michigan RN license, an Associate Degree in Nursing, and bilingual proficiency in Arabic and English. CPR/BLS certification is mandatory, with a preference for experience in value-based care or RPM programs.
associate degreebachelor degreeHIPAA CompliancePatient EducationCare CoordinationMedication ReviewClinical AssessmentChronic Care ManagementEHR ProficiencyRemote Patient MonitoringCMS GuidelinesChronic Disease ManagementPrincipal Care ManagementBilingual Arabic/English
Job description
Position Overview
We are seeking a compassionate, skilled, and bilingual (Arabic/English) Registered Nurse (RN) to join our Value-Based Care team. This role is dedicated to supporting patients enrolled in our Chronic Care Management (CCM), Principal Care Management (PCM), and Remote Patient Monitoring (RPM) programs at our Medical Center. The ideal candidate thrives in a telephonic care coordination environment, is passionate about chronic disease management, and is committed to building trusting, long-term relationships with patients through consistent outreach and education — without traditional bedside or in-person clinical duties.
Key Responsibilities
Manage an assigned panel of patients enrolled in CCM, PCM, and RPM programs through regular telephonic outreach and follow-up
Conduct structured phone-based assessments, medication reviews, and care plan check-ins in both English and Arabic
Monitor and review remote patient monitoring (RPM) data, identifying clinical changes and escalating concerns to the supervising physician or NP in a timely manner
Collaborate with physicians, nurse practitioners, and the care team to develop, implement, and update individualized care plans
Educate patients and their families — in both English and Arabic — on chronic disease self-management, medication adherence, warning signs, and healthy lifestyle practices
Document all care management activities accurately and in compliance with CMS guidelines for CCM and PCM billing (including monthly time tracking)
Proactively identify care gaps, social determinants of health, and barriers to care, and coordinate appropriate referrals and resources
Support patient enrollment and consent processes for CCM, PCM, and RPM programs
Ensure full compliance with HIPAA regulations, CMS value-based care standards, and Medical Center policies
Maintain thorough and timely documentation in the Electronic Health Record (EHR)
Qualifications
Current, valid Registered Nurse (RN) license in the State of Michigan (required)
Associate Degree in Nursing (ADN) required; Bachelor of Science in Nursing (BSN) preferred
Proficiency with EHR systems and remote patient monitoring platforms
Excellent communication, empathy, and patient engagement skills
Ability to manage a large patient panel, meet monthly documentation requirements, and work independently
Prior experience in an outpatient, care management, or value-based care setting preferred
Benefits
Health insurance
Paid time off (PTO)
Flexible scheduling
Opportunities for professional growth and development in value-based and population health
Pay: $26 – $34 per hour (commensurate with experience)
Work Location: In-Person | Medical Center – Remote
If you are a bilingual RN who is passionate about proactive, patient-centered chronic care and wants to make a meaningful difference in the lives of patients managing complex conditions, we encourage you to apply.
